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T H EP & SJ O U R N A L

Learning To Be A Doctor
(now)

By William Allstetter

When Morton Creditor’s essay on clinical education at P&S in the 1940s [see preceding article, “Learning To Be A Doctor (Then)] landed in the offices of P&S Journal, it raised a few obvious questions. Who are the outstanding teachers at the school today? Who will be lauded sometime in the next century by alumni certain that neither the education, the professors, nor the graduating physicians are as good as they were back in the 1990s? And what makes them such great teachers?

Teachers lack national boards and other objective, quantitative measures of teaching greatness. But they do have awards that recognize their teaching. Every year students finishing their first, second, and third years of medical school choose the best teachers for that year. The graduating class chooses its favorite teacher overall, the Distinguished Teacher of the Year, who is honored at commencement. The Charles W. Bohmfalk award, chosen by the committee on honors and awards and also presented at commencement each year, honors one teacher for pre-clinical instruction and another for clinical instruction. In recent years, the president of Columbia University has honored five teachers from within the entire university.

Students also fill out course evaluations for every course and teacher in the school. And conversations with students and faculty elicit the names of many whose lectures or leadership on rounds are inspirational.

Clearly, P&S has many great teachers. Through these various avenues a consensus begins to develop. Although many professors win teaching awards, only a handful win them again and again. A few professors consistently receive high course evaluations and are mentioned repeatedly in conversation. But some of these professors teach only one course, deliver only a few lectures, or lead rounds for a short time.

The truly great teachers at P&S have an impact on the entire student body. They instruct students at several stages during their medical education. They also have an additional influence on the education at P&S by recruiting other professors for the course, section, or clerkship they direct. When awards, course evaluations, and overall impact are all taken into account, Drs. Herb Chase, Andrew Wit, Jay Lefkowitch, Steve Miller, and Glenda Garvey emerge as among the outstanding teachers at P&S in the 1990s.

Each professor has a distinct style and distinct lessons that he or she emphasizes. But after talking to them, their students, and fellow faculty members, it becomes clear that these professors also share many of the same characteristics. Those similarities reveal much about what it takes to be an outstanding teacher and the education medical students receive at P&S today.

Herb Chase

Herb Chase: “I realized that the most I could do for patients is by teaching.”
Herb Chase: “I realized that the most I could do for patients is by teaching.”
Herb Chase was trained in internal medicine and nephrology and for many years ran a lab investigating basic issues in epithelial biology. But soon after the curriculum revision in 1993, Dr. Chase gave up his lab to devote himself to teaching, a unique and somewhat risky career move in an academic institution like P&S.

“I realized that the most leverage I could have, the most I could do for patients is by teaching,” says Dr. Chase, professor of clinical medicine. By helping to train 150 physicians each year, he could do more for patient care than either seeing individual patients or illuminating an important but narrow detail of epithelial biology.

Dr. Chase directs the major first-year course, “Science Basic to the Practice of Medicine” and teaches the first-year elective “Clinical-Pathological Correlation.” He lectures in pharmacology and pathophysiology during the second year, as well as being one of the teachers for “Physical Diagnosis.” In the fourth year, he serves as the nephrology consult attending physician and leads a journal club elective and tutorial.

Dr. Chase is renowned for the support he provides to first-year students. “Right from the start, I guarantee them success,” says Dr. Chase. He attends every lecture and on most days can be found after class surrounded by a knot of students, warmly chatting, answering questions, and offering suggestions for additional study. A few students are overwhelmed by the vast amount of information they must absorb in medical school and do fail that first test. Dr. Chase meets with them, explains strategies for mastering the material, and assures them that they do indeed belong in the class, that their admission to P&S was not a mistake.

“It’s definitely comforting. It makes you feel like someone is looking out for you,” says Livia Santiago-Rosado’99. “It gives you hope to keep you working.”

Dr. Chase attends every lecture in the course he directs, “Science Basic to the Practice of Medicine”
Dr. Chase attends every lecture in the course he directs, “Science Basic to the Practice of Medicine”
“Science Basic to the Practice of Medicine” subsumed cell biology, physiology, biochemistry, and genetics in 1993. For the past six years Dr. Chase has devoted himself to incorporating the information from those separate courses into a single integrated course. With feedback from students, faculty, and colleagues around the country, Dr. Chase has developed 120 “classic stories” of medicine. Rather than organize the material according to methods of observation, Dr. Chase has given the course a “functional spin” that focuses on how the body works, with lectures on topics such as the liver, the cell cycle, and ATP. While it is difficult to tell if this approach trains better doctors, the students do enjoy the course more, spend 40 percent less time in class, and have scored just as well on their boards.

Dr. Chase looks for teachers who bring something extra to the class. He loves teachers with charisma, ones who can entertain the class and make students say, “Wow!” It could be the professor who drops an egg to illustrate entropy or the assistant professor who is so clear that he can make history majors understand electrical conduction in the body. Dr. Chase also favors basic scientists as lecturers. Not only can they talk authoritatively about the cutting edge of science, students get to hear them outline the rigorous scientific reasoning they use in their research.

In a first-year elective, he presents students with case studies written for doctors. “You just sit there with a Harrison’s (“Principles of Internal Medicine”) and look up things and deduce what happened,” says Candice Chen’01. “You may not get it right, but you go through the process. That was great.”

In many cases, the students will have to consult the literature to learn about studies and experiments that are too new to have made it into reference books. Unfortunately, much of it is second rate, according to Dr. Chase. So students have to learn how to evaluate the literature.

“The students are entering an arena that is completely unlike anything we have faced before,” says Dr. Chase. The explosion of biomedical information in the past 20 years and instant access to it through the Internet can be a tremendous resource. Dr. Chase is an admitted Medline “addict.” But it also has the potential to swamp physicians in an information overload. “The physician of tomorrow needs to be a manager of information. But one with judgment.” Scientific reasoning provides that judgment.

Andrew Wit

Andrew Wit: “I try to establish contact with the class. You almost treat the large class like a small class.”
Andrew Wit: “I try to establish contact with the class. You almost treat the large class like a small class.”
Andrew Wit has been at P&S for 30 years, leading a lab that studies the basic science of arrhythmias caused by cardiac diseases. He got into teaching almost accidentally 12 years ago when he was persuaded to fill in temporarily as director of the major pharmacology course in the second year after the previous director moved on to something else.

“I really enjoyed it, so I stuck with it,” says Dr. Wit, professor of pharmacology. The smart, nice, talented students were “more than just grinds.” They were actually enjoyable to be around.

“He would dedicate any amount of time to his students,” says Cori Horn’00. In fact, when asked a question he will often explain and explain until a student says, “Stop, I understand.” Ms. Horn calls him the “voice of reason,” who is quick to respond to e-mails, whether they are written on the weekend from home or in a panic at midnight.

In class, Dr. Wit seeks interaction as well. “I try to establish contact with the class. You almost treat the large class like a small class,” says Dr. Wit. He walks around, he looks students in the eye, and he asks questions. “As soon as you start asking questions in a lecture you can get them thinking.”

Student responses are a clear indication of how well he is doing. “If you look into the audience you can see if they are getting it,” says Dr. Wit. “Are people interested? Or are they sleeping, talking, and reading? The feedback is right there immediately.” Students are apparently interested, because attendance is excellent.

During the course Dr. Wit doesn’t just give a long list of medications and their actions. He organizes the material around the disease process. “It’s sort of a logical thinking scheme,” says Dr. Wit. “You first think of how you can modify a disease process to make the patient better. If you know the process, you can target your drug therapy to alter it. Here is where knowing the mechanisms of drug action is more than just basic science; it has real clinical utility.

“I favor lecturers who can teach with a piece of chalk and a blackboard,” says Dr. Wit. A teacher with slides can race through a topic without taking the time to fully explain it. Writing on the blackboard forces the teacher to explain it slowly and completely, in an organized fashion, so the student can absorb it.

Dr. Wit also writes all the tests himself, even though others do much of the lecturing. The tests have to reflect exactly what the students need to know. During class he tries to make it explicitly clear what students are responsible for and what will not be on the test. He doesn’t like trick questions.

“You always recognize how well you have done by how well the students do on the exam,” says Dr. Wit.

In addition to directing the major pharmacology class in the second year, Dr. Wit also has developed a fourth-year course in clinical pharmacology with Dr. Elsa-Grace Giardina, professor of clinical medicine. “This was an entirely new experience for me and so different from the second-year course,” says Dr. Wit. “When the students leave the second year to enter the clinic, I worry about whether we have taught them sufficiently to enable them to perform well, have a good clinical experience, and satisfy their clinical preceptors. When I finally see them again in our fourth-year course, they are real physicians capable of analyzing cases and designing therapy. It makes me marvel at the educational process and how we turn college students into doctors. I feel good about having played some part in this.”

Jay Lefkowitch

Art, not science, brought Jay Lefkowitch to the attention of former pathology department chairman Donald West King, when Dr. Lefkowitch was a third-year student at P&S. Illustrating two of Dr. King’s textbooks got Dr. Lefkowitch interested in pathology. He enjoyed presenting pathology cases to residents and physicians during a subinternship on the autopsy service in his fourth year. And he accompanied Dr. King to Institute of Pathobiology conferences in Aspen after both his third and fourth years. He has gone on to become a world expert on liver pathology.

Jay Lefkowitch at his “Man in the Pan” session: “The thing I think is important is to simplify, to figure out the core of what a student needs to know.”
Jay Lefkowitch at his “Man in the Pan” session: “The thing I think is important is to simplify, to figure out the core of what a student needs to know.”
“Pathology. I never guessed that’s what I would be doing,” says Dr. Lefkowitch, professor of clinical pathology. “My story is one of how mentoring can change an entire career.”

Dr. Lefkowitch leads the pathology section of the second-year pathophysiology course, lectures to third-year students in the surgery clerkship, and teaches the pathology elective for fourth-year students.

Like Andrew Wit, Jay Lefkowitch is known for being able to clearly explain complex subjects. “The thing I think is important is to simplify, to figure out the core of what a student needs to know,” says Dr. Lefkowitch. Once he has done that he can organize his lectures. First he presents the big picture, the concepts a student needs to understand. Then he dives into the details behind the big picture and, finally, returns to the big picture to put those details in their place.

“He is able to make the hardest material clear,” says Robert Ross’99. “He takes what could be a boring subject and makes it fascinating.”

Part of that comes from Dr. Lefkowitch’s infectious enthusiasm. But it also stems from making pathology about more than slides and organs. Early Wednesday mornings he holds an extracurricular session known as “Man in the Pan” for second-year students. After bagels and coffee, supplied by the Department of Pathology, a pathology resident tells the clinical story of a person who died recently. The resident outlines the medical history, chief complaint, lab results, treatment, and the patient’s response. Throughout the half-hour presentation, Dr. Lefkowitch offers running commentary of the story and peppers the students with questions, often about topics they have not yet studied. Sometimes students answer correctly, sometimes incorrectly. But if they are wrong, he never seems irritated, disappointed, or critical.

“He’s just really accessible,” says Gordon Streeter’99. “He’s so into teaching that you feel more comfortable. You can ask him questions that you might not ask anybody else.”

Dr. Lefkowitch consciously fosters this persona. “What’s unique about me? Getting down and dirty, feeling that I am not too different from the students. I don’t have any formalities with them.” That becomes evident at the end of the hour when Dr. Lefkowitch and the students don rubber gloves and gather around the table and the dead patient’s organs. Everyone stands together, examining the organs, passing them around, sharing observations.

“I think it is a pleasure seeing people progress,” says Dr. Lefkowitch. But it isn’t just the students who benefit. Teaching forces him to keep abreast of current thinking in many areas of medicine that he might otherwise let slip.

And it helps in a way that Ponce de Leon would have admired. “Your students keep you young,” says Dr. Lefkowitch. “They keep you current.” In fact, he is now trying to think of a replacement for his Jane Russell jokes.

Steve Miller

Left, Steve Miller: “The skill of a teacher is to break down a complex task like clinical reasoning or patient interaction into its individual steps.”
Left, Steve Miller: “The skill of a teacher is to break down a complex task like clinical reasoning or patient interaction into its individual steps.”
Pediatrician Steve Miller, the youngest of these outstanding teachers, is also a P&S graduate. After a residency at Albert Einstein, Dr. Miller returned to P&S in 1993, where he is now director of the pediatric emergency room. He serves as a preceptor in the first-year course “Clinical Practice” and has organized the section focused on the life cycle and on the clinical and ethical issues relevant to various stages of life. In the second year, he leads sections on medical interviewing and transition to the clinic. He also directs the third-year pediatric clerkship.

Dr. Miller likes to give students a few basic procedures to help them simplify and structure their patient interactions. Whether it is a method for interacting more compassionately with patients or making a diagnosis and planning a treatment, he outlines a few steps to guide them.

“I try to show them that it is important to do things in a certain order. You gain confidence doing things again and again the same way,” says Dr. Miller, Arnold P. Gold Assistant Professor of Pediatrics. “That allows you to concentrate on listening to patients, connecting better with them.”

“He’s very into process,” says Cori Horn’00. “He’s famous for drawing decision trees.”

“You could go to any bedside and decide what to do if you use this tree,” says Dr. Miller. The actual nodes and branches are not written in stone. In fact, he wants students to develop their own decision trees. It is more a method for approaching the diagnostic task.

“A lot of experts have forgotten how to articulate what they are doing. It is important for us to unfold our clinical reasoning,” says Dr. Miller. “The skill of a teacher is to break down a complex task like clinical reasoning or patient interaction into its individual steps.”

In the first-year course he uses that strategy to make sure students treat the patient properly; “calibrating your own instrument,” he calls it. Before encountering a patient, a physician should follow three steps. First, make an assessment of his or her own biases, which can range from anything to not liking the patient to realizing that the argument with his spouse that morning has left him irritable. Second, think how that might impact care of the patient. Third, make a conscious decision to compensate for that bias and put the patient’s needs first. Contrary to many who think a person is born with or without a good bedside manner, Dr. Miller believes that bedside manner is a conscious skill that can be learned.

“I think there are some genuinely powerful ways to improve patient skills. It’s not a simple matter. It takes hard work,” says Dr. Miller. “You’ve got to respect where the patient is coming from.”

Dr. Miller also makes an extra effort to pay attention to the emotional lives of students. During the clinical reasoning seminar with students in the pediatric clerkship, Dr. Miller spends the better part of an hour asking how everyone is doing with their various assignments and leading a discussion of how to cope with the difficulties that inevitably arise.

In 1998, Dr. Miller also initiated a ceremony for students at the end of their second and third years. The departing third-year students give awards for teaching to their residents and advice to nervous second-year students preparing for their first full exposure to the clinic.

“He makes P&S a gentler place for the medical students and the patients,” says Robert Ross’99.

Glenda Garvey

Glenda Garvey talks fondly and with clear respect about the teachers she had, from elementary school all the way through her medical training at P&S. “I had wonderful, wonderful teachers,” says Dr. Garvey, professor of clinical medicine. It became clear to Dr. Garvey that she herself would someday teach after she presented a scene from “King Lear” to her classmates. “At the end of it I was flushed. I loved it.”

Dr. Garvey also studied at P&S, which to her was a grand adventure. After medical school, she studied internal medicine and infectious diseases. She organized the medical intensive care unit at Presbyterian Hospital in the 1970s and still directs it today. Dr. Garvey lectures and serves as preceptor in the second-year course, “Abnormal Human Biology.” She serves as co-director of the fourth-year “Advanced Pathophysiology” course.

It is as a clinician, however, that she is most renowned and held up as a role model. She is an attending physician for the infectious disease rounds for three months and the medical intensive care unit for six, more than any other faculty member. And she directs the medicine clerkship for third-year students, the longest and arguably most important clerkship for all students.

Dr. Garvey talks much about the “decorum” of being a doctor and sees the white coat as a potent symbol of a doctor’s responsibilities. “It’s a cloak, a cape. When you put on that coat, the personal sorrows are suspended and you become intensely involved in the other, in the patient,” Dr. Garvey said when she accepted the Distinguished Teacher of the Year award at the 1998 commencement.

Glenda Garvey: “That’s what is so important to learn as students, how to put themselves into the patient’s role and what they are experiencing.”
Glenda Garvey: “That’s what is so important to learn as students, how to put themselves into the patient’s role and what they are experiencing.”
“That’s what is so important to learn as students, how to put themselves into the patient’s role and what they are experiencing,” says Dr. Garvey. That is a big change for many of the third-year students. Dr. Garvey applauds changes in the medical training that have made professors less arrogant and disdainful and students willing to demand more. But in third year, students often have to be reminded about the priorities.

“You have gotten very good at taking your own pulse,” Dr. Garvey tells students beginning their clerkship. “Now it is time to take the patient’s pulse. In medicine, it isn’t about you. It’s about the patient who is coming to you, hoping you can help them.”

On rounds, which are infamous for their length, Dr. Garvey (a former English major) wants to hear the patient’s story. If some detail doesn’t fit or doesn’t make sense, the diagnosis has to be refined and reassessed relentlessly until the story does make sense.

She tells stories as well. “It opens up all the things that you want to teach,” says Dr. Garvey. She immediately launches into a story about Mr. Lynch, who fractured his wrist while clipping his hedge and ended up with a severe case of tetanus. The next time one of her students sees a case of tetanus, he or she will likely remember Mr. Lynch and the management of tetanus and the importance of prophylaxis even in unlikely situations.

When students or residents propose a treatment she always wants to know why they chose that treatment, what they expect will happen. She wants to hear details not only of disease, but of cells and physiology and molecular biology. She wants them to recall the science they learned in the first two years. “They know it all. It’s just bringing it into the proper context. You have to let them reason it out. They think it through and then they own it.”

She tells another story of a student working in the emergency room when she was the admitting resident. The student was struggling to decide whether a patient should be admitted. Within 10 minutes, Dr. Garvey had the patient not only admitted but rushed to the intensive care unit. The student was completely bewildered, feeling as if he had failed miserably at the basic diagnosis. But Dr. Garvey reassured him, pointing out that her experience made the difference. “It wasn’t magic. It had to do with the look on the patient’s face, the way his pulse felt,” says Dr. Garvey. “What I want to let them know is that we all can learn this.”

And that they will never stop learning. Dr. Garvey doesn’t. And neither do any of the great doctors. Not only is there too much for any one person to learn, both diseases and the knowledge of them keeps changing. That is both the challenge and the reward. “You can never sit back and say, ‘I’ve got it.’ If you do, you are probably wrong,” says Dr. Garvey. “I like that. Everything is always evolving in an interesting way.”

In fact, continuous learning is one of the common themes expressed by these teachers. Herb Chase teaches students the principles of scientific reasoning so they can learn more effectively throughout their lives. Jay Lefkowitch welcomes the prod that teaching gives him to keep up with current thinking. Linda Lewis, associate dean for student affairs, confirms that it is a core goal of the school: “You want to turn out people who are prepared to learn for the rest of their lives.”

“Your ability to problem solve depends upon how well you have organized information in your brain,” says Hillary Schmidt, assistant dean for curriculum evaluation and faculty support. As a cognitive psychologist, Dr. Schmidt has studied how people learn and remember. She notes that the outstanding professors also present material in terms that students can understand, then reinforce the lesson with a review, a summary, or “take-home lesson” that cements the information in their brains. They also engage the students. “The more active students can be, the more you can provoke them to think, the more enduring the lesson is.”

But maybe the most basic characteristic that these teachers share is their commitment to students. They invest large amounts of time and energy because they find it rewarding in a variety of ways. Jay Lefkowitch recognized that his teaching activities played an important part in his promotion to full professor. Support from the dean’s office and government grants for education made it possible for Herb Chase to devote his career to teaching students. Ron Drusin, associate dean for curricular affairs, confirms that teaching plays a role in promotion decisions and that teaching has become a more important factor at the school in recent years.

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